Insurance Coverage for Breast Reconstruction
In almost all cases, if your insurance plan provides coverage for the cost of a mastectomy it must also, according to Federal law, provide coverage for the method of breast reconstruction you wish to undergo; this coverage includes perforator flaps such as the DIEP, GAP and LAP flaps. This law applies both to reconstruction done at the same time as a mastectomy, and also to reconstruction done at a later date. If a surgeon in your network of participating providers does not offer the method of reconstruction you prefer, your insurer must still provide coverage, even if this means covering the cost of surgery with a “non-participating” physician.
We are continually trying to work with other insurers to increase the number of network in which we participate. If you are insured by a plan with which we do not participate, please know that our staff is very experienced in working with insurers to help you obtain coverage for breast reconstruction procedures, and we will be happy to answer questions you may have.
Regularly, we are able to obtain authorization for women who do not have access to “in-network” physicians offering perforator flap breast reconstruction to go out of their networks to have their surgery. We are often able to arrange for coverage, on an individual basis, for women with HMO plans, patients with self-funded ERISA plans, people who have previously been denied coverage for breast reconstruction surgery and for women with unsatisfactory outcomes from prior reconstruction. In all cases, we will work closely with you and your insurance carrier to minimize any out-of-pocket expenses.
For more information, please contact our office at 404-480-4888.
Overview of Federal Law pertaining to Breast Reconstruction
The Women's Health and Cancer Rights Act (WHCRA) of 1998 contains important protections for women who wish to have breast reconstruction after mastectomy. This law requires group health plans and individual health policies that provide coverage for mastectomies to also provide coverage for breast reconstruction.
In accordance with the WHCRA, members of group health plans receiving mastectomy-related services are entitled to:
Reconstruction of the breast on which the mastectomy has been performed
Surgery on the opposite breast to produce a symmetrical appearance (including reduction, breast lift or augmentation)
Treatment of physical complications at all stages of the mastectomy, including lymphedema
Additional information is available from the US Department of Labor, which has oversight of the WHCRA.